Cardiac Problems in Pregnancy, Las Vegas, 2016 Risk prediction and maternal mortality Cardiac disease as a cause of maternal mortality in Europe (Els) Petronella G Pieper University Medical Centre Groningen The Netherlands No conflicts of interest
Death Valley, 26th febr 2016
UN 2000 Milennium Development Goals Fifth goal: worldwide reduction of maternal mortality of 75% from 1990 2015 1990: 523.000 maternal deaths (385 per 100.000 births) aim for 2015: <130.000 deaths (96 per 100.000 births) actual maternal mortality rate in 2015: 216 per 100.000 births reduction 44% Alkema Lancet 2016
World Map Population per country worldmapper.org
Maternal Mortality Map worldmapper.org
Maternal Mortality rate per 100.000 births in 2015 Alkema Lancet 2016
ROPAC registry (1321 pregnancies) Maternal mortality in women with heart disease developed countries 0.6% developing countries 3.9% p < 0.001 Roos-Hesselink EHJ 2013
16 UK direct and indirect maternal mortality rates Rate per 100.000 maternities 14 12 direct and indirect 10 8 indirect 6 4 direct 2 Mid-year for each 3-year period 2004 2005 2006 2007 2008 2009 2010 2011 2012 MBRRACE Knight M dec 2015
2 Causes of maternal deaths UK 2011-2013 Rate per 100.000 maternities 1.5 Direct deaths Indirect deaths 1 0.5 0 MBRRACE Knight M dec 2015
acute unexpected
Rare diseases atypical presentation
High mortality Dissection 80% Infarction 7% Huisman PlosOne 2013 Elkayam Circ 2014
Other causes: Endocarditis Myocarditis Prosthetic valve complications Other valvular disease Congenital heart disease Pulmonary hypertension
Cardiac maternal mortality in Turkey Different causes than UK / Netherlands Roos-Hesselink EHJ 2013
Maternal Mortality Rate per 100.000 births in 2015 Turkey 2007-2009 Maternal Mortality Rate 19.7 Alkema Lancet 2016 Engin-Ustun J MatFet Neon Med 2012
Maternal mortality in Turkey More direct than indirect deaths (36.6%) main cause cardiac disease Turkey UK, Neth Cardiomyopathy, Ischemic heart disease, 25% 53% Dissection Valvular disease 26% 4% Engin-Ustun J MatFet Neon Med 2012
Maternal mortality in Turkey More direct than indirect deaths (36.6%) main cause cardiac disease Turkey UK, Neth Cardiomyopathy, Ischemic heart disease, 25% 53% Dissection Valvular disease 26% 4% mainly rheumatic heart disease Engin-Ustun J MatFet Neon Med 2012
Maternal mortality in Turkey More direct than indirect deaths (36.6%) main cause cardiac disease Turkey UK, Neth Cardiomyopathy, Ischemic heart disease, 25% 53% Dissection Valvular disease 26% 4% mainly rheumatic heart disease mainly prosth. valve thrombosis Engin-Ustun J MatFet Neon Med 2012
Can maternal mortality in Europe be further reduced? Both UK, Turkey, Netherlands: High maternal age, risk factors (obesity, smoking, hypertension)
UK: Indirect deaths (including cardiac causes) 50% BMI > 25 Can maternal mortality in Europe of which 2/3 obese) be further reduced? Both UK, Turkey, Netherlands: High maternal age, risk factors (obesity, smoking, hypertension) UK: Indirect deaths: 29% obese, 21% overweight Obesity: risk of acute manifestations of cardiac disease in previously healthy women (i.e. myocardial infarction) increases risk of complications in women with pre-existing heart disease (hypertension, pre-eclampsia, hemorrhage, thrombo-embolic complications, infections)
Recommended weight gain Nat. Institute of Health, ESC guidelines BMI recommended weight gain < 25 11 16 kg 25-30 7 11 kg > 30 7 kg
Can maternal mortality in Europe be further reduced? Substandard care UK Netherlands: 28% Turkey: no data MBRRACE Knight M dec 2015
Can maternal mortality in Europe be further reduced? Substandard care: Failure to consider infarction or dissection in women with chest pain Failure to diagnose pulmonary edema or delay in diagnosis No preconception counseling Inappropriate management of anticoagulation therapy Inadequate communication between medical staff Saving mothers lives 2011
Reduce maternal mortality: multiple strategies Acute heart disease in previously healthy pregnant women is often not recognized: education of obstetricians and midwives Reduce risk factors (smoking and obesity) in all women who pursue pregnancy and in women with pre-existing heart disease Pre-conception counselling for all women with heart disease Screening of women with family history of CM or SD Well organized multidisciplinary care (communication, management protocols) Not only review mortality but also severe morbidity Saving mothers lives 2011
Can maternal mortality in Europe be further reduced? Annual reduction of 1% in governmental health care spending: Increase of maternal mortality 10.6 % during that year (N=89) Increase of maternal mortality 9% in year thereafter (N=75) Multivariate analysis: increased mortality through changes in provision of skilled health professionals Study concentrated on direct deaths only Maruthappu 2014 BJOG